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WORKERS'COMPENSATION DECLARATION 76M444 I
CE 875(11-84) MISCELLANEOUS APPLICATION
I 1affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insurewie,, o or a certificate of Workers'Compensation Insurance,ior
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING I
ADDRESS
FiCertified copy is hereby furnished. BUILDING ) ..Z i LOCALITY 10L
ADDRESS . OL
DCertified copy is filed with the county building inspection LOCALIT53 NEAREST
department. e CAL4 CRO ss ST.
Date Applicant NEARESTt D(,l���T�@'IC N G �fP� TYPE P CESS BY
CROSS ST. 11 - 2 Cr/ V / ` �( CONST.
CERTIFIQATE OF EXEMPTION FROM WORKERS' LEGAL ✓ `J
COMPENSATION INSURANCE DESCRIPTION LOT NO. t• NO. (CIRCBLOCK MAP (CIRCLE)AY STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 5ckoq NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT l - EXISTING BLDG.�e�3� 3 >'
I certify that in the performance of the work for which this CD
permit is issued, I shall not employ any person in any manner OWNER — v\ P_r-L
so as to become subject to the Workers' Compensation Laws. MAIL ttLL 1 p OCCUPANCY GROUP I "^�r o
Date Applicant
ADDRESS S � 10- 0..S.
NOTICE TO APPLICANT: If, after making this Certificate of CITY7.e_„,L L,`,(�• rNHO L.0tq �j�94154Q-1 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICA ION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIPanic Devices
ON
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and ` 7 • •��
effect. Q. 7/. PARKING REQ'D PROVIDED
l— SPACES II��JJ
License Number Lie. Class h% 6 ' L: ''+
LIMITED TIME USE
Contractor Date £ flo r ecL-L DATE DATE
FROM: TO:
EJ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF Q NO. OF a ISP
SNATUVM
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. \ STORIES I
iness and Professions Code). p O
PRESENT USE OF BUILDING %,= L•4 FINAL APPROVAL j
Lie.or Reg.No. Date ii I
L L Z.e Ji Xe,yuG
HOME OWNER-BUILDER DECLARATION No. o EXISTING HUI DINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ACCs T o T
License Law for the following reason (Section 7031.5, Busi-
ness
usi 33-107 93.013ness and Professions Code): NO. PARKING
SPACES PROVIDED ir— +'
❑ I, as owner of the property, will do the work and the 1 ITEMO
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL 93 m 00
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 93.011
I hereby affirm that there is a construction lending agency CHANGE .00
for the performance of the work for which this permit. is
issued(Sec. 3097,Civ.Q.
Lender's Name 01000-0001 5/ q./9 I
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE � 135 13 1 Aid 9:45
I certify that I have read this application and state that the I✓
above information is correct.I agree to comply with all County ISSUANCE FEE
1heby
es and S laws relating to building construction,
and aurize pre ntatives of this County to enter TOTAL.FEEupoabove- entioneJp Mert. nsp tion purpo S. SEE REVERSE FOR EXPLANATORY LANGUAGE
� L11�' `u
Signatu a of Permittee Date